Public Health and the New Era of Digital Decisioning

For critical healthcare decisions, a rules engine must be more than just modular—it must perform reliably under enormous load. Progress Corticon has evolved to solve the challenge of both scalability and modularity.

State leaders have been emphasizing modularity in their IT architectures to a greater extent than ever in recent years, and recent federal policy has further stoked the focus. However, according to the annual 2018 State of State Health & Human Services Technology Programs Survey, by the American Public Human Services Association, modularity still has not seen much movement in adoption rates year over year despite prodding from federal policy. However, tackling the bear that is modernization is made easier through employing existing tools, but in new approaches.

Progress Corticon, the business rules engine used by public-sector agencies in more than half of the US states, is one such tool that is constantly evolving to address new citizen service initiatives through interoperable workflows. These initiatives have followed the maturity curve of the various open standards for technology design, communication and terminology.

For example, HL7’s Fast Healthcare Interoperability Resources (FHIR) Specification has created the frameworks for exchanging healthcare information electronically. With Corticon, agencies can take common terms defined in these standards such as, “a patient,” “a procedure,” “an observation,” or “an order” to build easy to author and interpret, interoperable, scalable Decision Services.

A Primer on Corticon within Health and Human Services

State Health & Human Services agencies are always on the lookout for ways to replace legacy systems and to automate paper-based processes, such as enrollment and eligibility. Due to well publicized struggles between some technology vendors and states stemming from unsuccessful projects, these innovations require scrutiny by policymakers, technology architects, constituents, and most importantly end-users. Through this scrutiny, Progress Corticon rose to prominence as the rules engine that has never had a failed implementation, delivering unparalleled performance to states that needed to right the ship.

Enrollment and Eligibility with Corticon

Agencies find that merging business processes and business rules offers an agile approach to their goals. Enrollment and eligibility processing for Health and Human Services programs often requires making mission-critical decisions thousands of times a day, and millions or billions of times in batches. Such decisions include:

• Modified Adjusted Gross Income (MAGI) calculations
• Copay Rules: Client responsibility amount
• Batch Processing of existing members to address potential changes in household size, ages, employment, etc.
• Reimbursement Rules: The decisions on appropriate pricing methodology to apply
• Third Party Liability Rules: Services are covered by carrier-specific rules allowing cost avoidance and recovery
• Assignment Plan Rules: The services to carve out of a capitated managed care plan
• Fraud Detection and Waste Mitigation: To reduce unnecessary and at times fraudulent costs
• Online Screening: Business rules used to determine eligibility or ineligibility for one or more programs
• Benefit Simulation: Rules used to calculate “what-if” benefit amounts based upon selected programs
• Eligibility Determination & Benefit Calculation: Business rules are used to determine the proper eligibility & benefit calculation
• Overpayments/Benefit Recovery: Rules automatically determine overpayments based upon additional case detail

A common requirement of managing enrollment and eligibility is the orchestration of workflows. Simple decisions can be easy to manage. However, business managers may be uncomfortable making subjective decisions, or may struggle to represent decision-making logic in a process diagram. Moreover, decisions that are more task-oriented, such as an assessment of an applicant’s eligibility level for benefits, cannot effectively be conveyed with a process diagram.

Typically, this type of decision is managed behind the process diagram, as script, as code, or within a separate application. Just as common though are individuals making these types of decisions outside of any application; making key decisions at points within a process that are impossible to audit or optimize.

Business Rules Management Systems (BRMS) are designed to solve exactly this problem and can be integrated into existing infrastructures as reusable resources. Rules and process are logically separated so that they can be managed independently. Rules—defined as the business logic governing decisions—are represented in the form of “rule models.”

Agencies use existing case management systems, but instead of embedding rules in the same language upon which they’re built, such as Java, .NET or COBOL, the systems call the rules engine using open standards at the point when a decision is required. Requests are made specifically to the decision service that is going to process and deliver the decision, and the rules engine returns a response. It also provides an audit trail of exactly which rules fired, the order in which they fired, and the legislation, policy and people to which they’re tied. The Pennsylvania Department of Human Services, for example, relies on Corticon to power its Medicaid eligibility system and Children’s Health Insurance Program case management function. DHS’s uses for Corticon include:

• Triggering client notices
• Determining what verification information a client still needs to provide
• Evaluating data for data exchange and the income eligibility verification
  system to see what information is new and needs to be acted on
• Determining child care program enrollment funding sources and which child
  care providers require additional review to support the department’s
  quality goals
  

For critical decisions like these related to a person’s healthcare, a rules engine must do more than just be modular. It must perform reliably under the performance load of entire populations. By using Progress Corticon, the agency solved the challenge of delivering both scalability and modularity.

Progress Corticon has been successfully implemented by the majority of US states as the Business Rules Engine of choice, driving smarter, faster business automation across agencies. To learn more about how states are succeeding with Corticon, read the full paper here.  

Read the Whitepaper